Purpose. The purpose of this chapter is to establish the Patient Registration-System (PRS) as the Indian Health Service (IHS) official means for collecting, identifying, and recording patient demographic and eligibility information. This chapter of the Indian Health Manual (IHM) establishes the policy, procedures, responsibilities, and program elements for the PRS in IHS. The PRS assists IHS clinical and administrative staff by:

Providing An Automated User Population Data Base. Efficiency at the service units is improved by the automated PRS through an accurate, current, and consistent data base of information on IHS user populations. This PRS provides a master patient index to supplement the manual patient index file that must be maintained as a permanent resource.

Providing Information Support to Health Programs and Special Initiatives. The PRS assists in providing a data base for the following health care delivery support systems:

Health Issues/Disease Registers.

Health Issues Tracking. The PRS provides an interface at the Division of Data Processing Services (DDPS), IHS Headquarters West, with IHS workload data systems to obtain information on the incidence of health problems by community and service unit.

Epidemiology Studies. Health care facilities can use the information available from PRS data base to develop special disease registers. Other patient oriented files can also be established to support the immediate needs of local health care delivery staff.

Demographic Bases.

Program Planning. Patient demographic data from the PRS is used to support resource allocation and other planning needs involving patient care systems and health service delivery programs.

Target Programs. The PRS provides the ability at the facility level to generate listings of patients by community, age, sex, and other demographic criteria.

Allowing Interface with Other Data Base Systems. The PRS interfaces with other Resource and Patient Management System (RPMS) programs that require patient data. This avoids duplication of data input and ensures accuracy of patient information.

Assisting with Resource Allocation. Information regarding patient eligibility for third party information is available from the PRS data base for efficient management of the following:

Maximum Utilization of Third Party Resources. The PRS provides data to support such programs as the automated Medicare and Medicaid billing system, contract health services (CHS), and private health insurance billing.

Policy. New patients must be registered in the IHS facility data base prior to being provided health care services; however, emergency services should not be delayed. Information on patients who present a critical emergency that requires immediate medical attention must be obtained from the patient's relative or other accompanying individual. Each patient's IHS registration information must be updated on each subsequent visit to the facility by personal interview conducted by a designated IHS facility staff member. The patient registration process at each IHS facility must be accomplished by using the IHS Patient Registration (REG) software and the technical guidelines in Chapter 2, "Patient Registration" of the IHS Business Office Manual.

Background.

Historical Mandate for the Patient Registration System. IHS developed the automated PRS to provide a system at the local level for identifying patients, assisting in patient record development, and providing accurate updates of patient information. The accuracy and reliability of this data base is vital for resource requirements, legal requirements, and resource allocation determinations.

Prior to the development and implementation of the automated PRS in 1983, population data were based entirely upon census population figures and all patient data were processed manually. Efficient facility planning, resource allocation, and development of Third Party revenue resources required a modern automated system.

Legislative Authority.

Snyder Act. The Snyder Act (25 U.S.C. 13, November 2, 1921) provided the authority to assist "Indians throughout the United States for relief of distress and conservation of health." In 1921 Congress initially gave this authority to the Bureau of Indian Affairs (BIA), Department of the Interior.

Transfer Act. The Transfer Act, Public Law (P.L.) 83-568, transferred the authority for health care of Indians to the Public Health Service on August 5, 1954.

Indian Health Care Improvement Act. The legislative base for authorization to collect from private insurance is contained in the Indian Health Care Improvement Act, P.L. 94-437, Amendments of 1988. Title IV, Sections 4.01 and 402, provide Medicaid and Medicare authority with reference to the Social Security Act, particularly Section 1880 of that law which contains the authority for IHS to collect from Medicare. Section 1913 of the Social Security Act contains the authority for IHS to collect from Medicaid.

Core Data Set Requirements. On January 22, 1992, the final notice of the Core Data Set Requirements established by the Director, IHS, was published in the Federal Register (Vol. 56, Number 14) establishing a set of core program data elements that all IHS programs and facilities are required to submit for the IHS national data base.

The Core Data Set requirements fulfill several purposes, including meeting the management information needs of IHS and tribal contractors (P.L. 94-437, as Amended, 925 U.S.C. 1662, Section 602). The PRS core data set requirements include reporting record formats and guidelines on the use of the Social Security Number (SSN) as a patient identifier.

2-6.2 RESPONSIBILITIES.

Director, Indian Health Service. The Director, IHS, is responsible for ensuring that a system for determining patient eligibility for IHS health care services is developed and operational in each IHS direct care facility, and that the system is made available for use by IHS funded tribally operated health care facilities.

Office of Health Programs. The Director, IHS, has designated responsibility for the IHS PRS to the Chief, Health Care Administration (HCA) Branch, Division of Health Care Administration/Contract Health Services, Office of Health Programs (OHP). The responsibilities of the HCA include the following:

Develops General Policies. Establishes general policies regarding administration of the PRS program in IHS.

Maintains Area Standards of Performance. Establishes standards of performance for Area operations for patient registration.

Conducts Data Accuracy Evaluations. Management control reviews and quality assessment mechanisms are utilized by the HCA to assess the overall data accuracy of each Area. The HCA makes determinations as to the types of data collection and reporting needed, and recommends improvements.

Evaluates Overall Program. The HCA assesses the effectiveness of the PRS at the Area Offices and the service units. The long-term purpose and direction of the PRS is continuously evaluated by the HCA to ensure maximum effectiveness in meeting the health needs of IHS beneficiaries.

Develops Plans. The HCA develops long-term plans and objectives for continuous improvement of the PRS in consultation with appropriate agencies and tribes.

Provides Staff Assistance on Policy Issues. The HCA is responsible for providing staff assistance to the Area offices in matters of general policies and procedures regarding patient registration. The training for Area office staff is coordinated by the HCA.

Area Offices. Each IHS Area Director must ensure that the PRS is implemented and operational at each Area IHS direct care facility. The Area Directors must designate an Area System Manager (ASM) for the PRS who shall be responsible for:

Providing Technical Staff Assistance and Training. The ASM is responsible for providing and coordinating technical staff assistance and training to the service units for the day-to-day operation and utilization of the PRS. Within regulations, policies, procedures, and budgets established by IHS Headquarters, the ASM shall develop and recommend overall policies and methods for the technical direction, control, review, and evaluation of the Area and service unit PRS.

Establishing Service Unit Standards of Performance. Develops and recommends standards of performance for the service units' operation of the PRS.

Evaluating Service Unit Programs. Reviews and evaluations of the patient registration program at service units shall be conducted by the ASM to ensure high-quality service delivery and system functions. Reviews and evaluations conducted shall be consistent with methodology developed by the HCA, OHP.

Providing Advice on Patient Registration Issues. The ASM shall be responsible for identifying opportunities for improvement of the PRS and advising IHS Headquarters on suggested policy, procedural, and/or technical changes.

Monitoring Data Accuracy. The ASM monitors and updates submissions from field facilities, and informs the data center and IHS Headquarters of problems or suggestions for improvement.

Service Units/Tribally Operated Programs. Each service unit director/health program director must designate a facility PRS manager who is responsible for the following:

Maintaining Consistent Operations. Follows the guidelines and policies for the -day-to-day operation of the service unit PRS and ensures practices are consistent with Area and Headquarters guidelines and priorities.

Assuring Accuracy of Data. Ensures the accurate and timely updates to data in the PRS. The service unit-PRS manager submits reports of corrections of PRS data to the Area office in a timely manner. These reports may include such items as reimbursements, registrations, duplicate registrations, and mismatches.

Conducting Quality Assurance Monitoring. Establishes and implements a method for monitoring the quality of the facility PRS and coordinates resolution of quality issues with the service unit management team. This process is used to identify and address opportunities for improvement in the service unit PRS.

2-6.3 PATIENT REGISTRATION DEFINITIONS

The following are definitions of specific components of the PRS. These definitions are in addition to guidance provided in Chapter 2, "Patient Registration" of the IHS Business Office Manual.

Blood Quantum Codes.

Indian Blood Quantum. Blood quantum refers to the percent of Indian ancestry. Blood quantum is not an IHS criteria for eligibility for Direct or CHS services. However, many tribes have established a blood quantum criteria for their tribal membership. This decision then does affect eligibility for care.

Tribal Blood Quantum. The average percentage of blood quantum of all tribal members of the specific tribe of which the patient is a registered member.

Contract Health Service Delivery Area (CHSDA). The CHSDA is the geographic area within which contract health services will be made available to the members of an Indian community who reside in the area. The CHSDA is determined by: reservation boundaries; counties that include all or part of a reservation; and any county or counties that have a common boundary with a reservation; or States that are designated as a CHSDA (for example: Alaska, Nevada, and Oklahoma).

Indian. A person of Indian descent designated by a tribe as being Indian, residing in the Continental United States; and Indians, Aleuts, and Eskimos in Alaska.

Indian Health Programs. The health services program for Indians administered by the IHS within the Department of Health and Human Services.

Indian Tribe. Any Indian tribe, band, nation, group, pueblo, or community, including any Alaska Native village or Native group, which is federally recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians.

Reservation. Any federally recognized Indian tribe's reservation, pueblo, rancheria, or colony, including former reservations in Oklahoma, and Alaska Native regions established pursuant to the Indian Allotment Acts and the Alaska Native Claims Settlement Act.

Tribe Codes. A three digit numerical code assigned to each tribe that is officially recognized by the Federal Government.

Tribally Operated Programs. The health care programs which are managed by the tribes according to the legal provisions, which encourage eventual Native American control over their own health care system. The Indian health programs in some states are entirely tribally operated (for example: California.) Other States have a mixture of these and IHS programs.

2-6.4 ELIGIBILITY. The patient registration staff must be conscientious in obtaining and recording comprehensive and accurate data during patient interviews. The information collected and recorded in the PRS is used to determine an individual's eligibility for IHS direct health care services and Contract Health Services (CHS) from the IHS. This must include documentation from the BIA concerning each individual's tribal affiliation and membership status.

Registration of Patients Eligible for Direct Care. Patient registration staff must enter into the PRS the data collected on each patient who is eligible for direct care at the registering IHS facility and who has been assigned an IHS medical record number into the PRS.

General Eligibility Criteria for Direct Care. Services will be made available, as medically indicated, to persons of Indian descent who belong to the Indian community serviced by the local IHS facilities and program. The IHS may provide an individual with health services if the community in which he/she lives regards him/her as an Indian.

In accordance with the current law, IHS may use such factors as tribal membership, enrollment, residence on tax-exempt land, ownership of restricted property, active participation in tribal affairs, or other relevant factors in keeping with general BIA practices in the jurisdiction. However, it should be the patient's responsibility to obtain appropriate BIA documents.

In case of doubt as to whether an individual applying for care is within the scope of the program, the service unit director (or designee) shall obtain information from the appropriate BIA or tribal official in the pertinent jurisdiction regarding the individual's continuing eligibility.

Pregnancy. Services will be made available, as medically indicated, to a non-Indian woman pregnant with an eligible Indian's child, but only during the period of her pregnancy through postpartum (generally about six weeks after delivery, unless the provider determines there are pregnancy induced health care problems that do not resolve by six weeks.)
In cases where the woman is not married to the eligible Indian under applicable State or tribal law, paternity must be acknowledged in writing by the Indian or determined by order of a court of competent jurisdiction.

Disease Control. The service unit must provide medically indicated services to non-Indian members of an eligible Indian's household if the medical officer in charge determines it is necessary to control an acute infectious disease, or if it presents a public health hazard.

Emergency Care. If the patient's condition is such that immediate care and treatment are necessary to prevent danger to life or limb, services must be provided even while pending notification of eligibility.

A medical record will be made for all patients receiving emergency care. If the pending identification does not confirm the patient as an Indian beneficiary, billing can be done after the emergency care is received.

Priorities for Care. Priorities for care and treatment will be determined on the basis of relative medical need. Access to other arrangements for obtaining the necessary care will also be a determinant, because the IHS is the "payor of last resort" after the patient has utilized his alternative/third party resources and benefits.

The IHS facility will enter into the Patient Registration System those persons who are eligible for contract health services. Generally, for a person to be eligible for CHS he/she must meet the following residence and tribal membership requirements:

Residence Requirements: Resides within the United States and within a reservation or within a CHSDA.

Tribal Membership/Relationship Requirements:

Is a member of the tribe or tribes located on that reservation or is a member of one of the tribe or tribes for which the reservation was established; or

Maintains close economic and social ties with that tribe or tribes.

2-6.5 OPERATIONS GUIDELINES.

System Overview. The IHS PRS software allows for the entry of new patients' and for editing existing patients' registration information. The service unit PRS manager shall ensure that accurate data is maintained and transmitted to DDPS.

Entering Patients in the System. The service unit has the responsibility to encourage all patients who are registered to present any documentation they might have relative to their eligibility for IHS health care services and alternate resources. These documents will greatly assist in maintaining accurate patient information in the PRS data base.

Patients must be requested to bring their Social Security card, private insurance identification, and other information (such as proof of tribal affiliation and blood quantum) to initial or subsequent patient registration interviews. It should be explained to the patients that such information will expedite the patient registration and eligibility determination process. It is important to keep patients' mailing addresses and personal information files updated so that all health care benefits can be identified and expedited, and be utilized by the health care provided.

Mandatory/Critical Fields. The service unit patient registration staff must obtain and enter information in the following PRS fields. The fields considered mandatory are noted by an asterisk (*).

Name *. The patient's full legal name must be entered in the PRS preceding each visit, otherwise duplicate records may be generated. Check for different name spellings to ensure that the patient does not already have a health record number. Names cannot be changed unless legal documentation is provided by the patient.

Health Record Number *. Each patient should have only one health record number at a facility or service unit. When entering this number in the system, check for an exact match within the files of the facility.

Date of Birth *. The date of birth is one of the field identifiers from the patient file that is used to search for potential duplicates. Verify the date of birth to ensure there are no different entries that would imply different patient files. If the 'official' Social Security date of birth is in error, assist the patient in notifying the Social Security Administration (SSA) to make a correction. Date of birth should not be changed unless the patient provides a birth certificate or other certified legal document. Otherwise, use of the wrong date of birth will generate an error report.

Sex *. This notation would be either 'F' for female or 'M' for male This is one of the field identifiers used to search for potential duplicate files.

Social Security Number (SSN). For all persons ages two and above it is strongly encouraged that they have a SSN, according to IRS requirements. Therefore, all patients are strongly encouraged to obtain a SSN for their children at birth. Application forms for obtaining a SSN can be provided to patients.

Even though having a SSN is not mandated, it is extremely beneficial in identifying patient records. If possible, maintain a photocopy of the Social Security card in the patient's record at each facility where he is treated to verify the SSN. This number must be recorded accurately because it is a major identifier of the patient for third-party billing. Use of "pseudo numbers" will generate error reports.

Tribe of Membership/Tribe Codes *. The list of recognized tribes is already in the Patient Registration System to be accessed in order to match and update the tribe of membership information provided by the patient.

It is important to obtain verification of tribal membership, proof of Indian descent, and to maintain a photocopy of the certificate in the patient's record, or maintain a verified notation regarding the page of the tribal documents that indicates the individual's membership.

>The complete listing of tribe codes is in the User Guide/Standard Code Book Tables (Vol. II.) May 24, 1991, provided by the data center in Albuquerque, New Mexico.

Indian Blood Quantum *. The actual blood quantum fraction of the patient must be entered into the PRS as verified with BIA documents. Since membership in a tribe is important to eligibility for CHS, a notation regarding verified blood quantum will be made in the Patient Registration System. (Making an entry in this PRS field is required to continue in the database as it is presently structured.)

Present Community/Community of Residence *. This refers to the community in which the patient currently resides, and may not be the same as the mailing address. Be sure to indicate when the patient moved to their present community because official residence affects CHS eligibility.

Beneficiary Code *. This is the primary classification under which this patient qualifies for IHS care. Until the present law is amended, patients are usually qualified because they possess Indian blood.

Eligibility Status *. The types of eligibility for the patient will be determined based on the accuracy of the various data entered in the Patient Registration System.

Veteran Status *. Verify, if possible, the veteran status of the patient. This is important to determine potential eligibility for other services. Veteran information may include items such as: branch of service; service entry date service separation date; and Veterans Administration medical care eligibility.

Entering Third-Party Information. Because the IHS is the "payor of last resort" it is important that the patient registration staff collect accurate and timely data regarding the patient's Third-Party information.

Medicare. In utilizing the various fields in the PRS for the Medicare section, the following should be of special concern:

Medicare Eligibility Date

Medicare Termination Date

Medicare Release Date

Medicare Number/Suffix

Medicare Name and Date of Birth

Type of Coverage

Signature on file (early) for Part B

Medicaid. In entering information in the various fields pertaining to Medicaid, the following should be of special concern:

Medicaid State

Medicaid Number

Insured Person

Medicaid Name and Date of Birth

Medicaid Eligibility Date

Eligibility End Date

Primary Care Information (for Area specific applicability)

Private Insurance. Since the IHS is the "payor of last resort," this means it is vital to be accurate and complete about the patient's other sources of health care coverage or benefits. In the various information fields in the Private Insurance section of the PRS, special attention must be made to the following items:

Private Insurer(s)/Employer Name - verify, if more than one policy

Private Insurance Policy Number

Name of Insured

Private Insurance Eligibility

Type of Coverage/Group Number

Effective date/Termination date

Additional Category - Qualified Medical Beneficiary (OMB): This benefit is for patients whose income is below the poverty level. They may qualify for only Medicare benefits, or for both Medicaid and Medicare benefits.

Automatic Entries. A number of data elements, including the following, are automatically entered into the patient's computer record during the registration process:

Date Established

Date of Last Registration Update

Health Record Facility

Date Added to File (Current Community)

User Establishing the File

User Last Updating the File

Date of Last Update

2-6.6 PRS MANAGEMENT CONTROL SYSTEM.

Patient Registration Data/Cornerstone for Patient Health Care Programs. The information generated through the PRS forms the cornerstone for the entire facility and IHS-wide data base. All of the other IHS RPMS automated systems key off the patient registration information from each facility (service unit), because it is transmitted to the Division of Data Processing Services (DDPS), Albuquerque, New Mexico, for national reporting. Therefore, it is vital that the PRS information is current and accurate.

Federal Managers Financial Integrity Act (FMFIA) Compliance. Headquarters (HCA), Area offices, and service units must document policies and practices - that allow management to effectively monitor the PRS in accordance with the requirements of the FMFIA. A formal Management Control System (MCS), must be developed by the HCA, OHP, and approved by the IHS Management Control Officer (the Associate Director, Office of Administration and Management), and implemented by the HCA. The MCS provides coverage for complete and current IHS policies and procedures for the PRS, the conduct of regularly scheduled reviews of all PRS operations at all IHS Areas and services units, and continuous improvements to the IHS PRS.

The Associate Director, OHP, Chief, HCA, and IHS Patient Registration Coordinator at Headquarters, as the PRS Management Control Area Managers, shall develop a MCS that:

Focuses on Continuous Quality Improvement. The quality improvement process shall ensure that management systems and policies for the PRS are basically positive and effective. This includes completing policies and procedure revisions to improve service and quality outcomes that meet customer (client and patient) needs.

Continuous quality improvement in the PRS concerns the interface of functions across departments and services. The focus is on determining how the system itself can continue to be user friendly, and its effectiveness improved through the active involvement and participation of staff from all organizational components.

Emphasis must be placed on a proactive (preventive), not reactive, action, and on concurrent not retrospective evaluation. This is a different orientation from being problem focused and addressing problems after they have been identified and caused system complications.

Maintain a Systematic Approach. The success of the continuous improvement process is due to the concurrent focus on all segments of the organization. This results in an improved patient service. The continuous improvement process has a positive impact on the PRS.

Patient Service/Sensitivity. It is important that all IHS staff are sensitive to IHS patients cultural values and concerns for privacy. Patient registration is a vital part of each IHS facility's public relations program and patient registration staff should receive continuous management support for maintaining skills in communicating with the patients and assuring the patients' comfort during the interview process.

Privacy Act of 1974. Confidentiality of patient information collected must be maintained at all times in accordance with the Privacy Act of 1974. The registration staff must periodically review the Privacy Act.

Program Integrity. The integrity and accuracy of the patient registration data base is necessary because it is the core of many IHS systems and has a direct effect on many IHS applications requiring workload and population data. All third-party, information (Medicare, Medicaid, and private insurance) for patient must be accurate.

This information assists the Area Offices in collecting third party revenue for eligible patients who are treated in IHS and contract facilities.

2-6.7 TECHNICAL RESOURCES AVAILABLE.

More detailed technical guidance and information regarding the IHS PRS and procedures for completing patient registration are available in the following publications through the Area Offices:

User's Guide. The IHS Patient Registration User's Guide (Vol. I-II), published May 24, 1991, by the DDPS in Albuquerque contains explanations of the various types of reports published by the data center (Vol. I) and the various code lists (Vol. II).

User's Manual. The IHS Patient Registration User's Manual, by the Office of Information Resources Management in Albuquerque contains detailed directions for the users of the PRS in the service units.

User's Guide Addendum. The IHS Patient Registration User's Guide Addendum contains modifications to support the SSN collection, as well as other information. The SSN will be the major identifier for patients in the PRS.

IHS Patient Registration Examples. The IHS Patient Registration Examples published by the Division of RPMS in Albuquerque gives visual examples of the various computer screens in the PRS. This is of great assistance to technical staff working directly with the systems in the service units.

Business Office Manual. An excellent source of information on the overall functions of the PRS is the Business Office Manual. The three-ring-binder format provides for easy additions of new information regarding patient business services and is continually updated to reflect system changes and modifications. The Business Office Manual developed by the Headquarters Strategic Initiative Team Office of Health Programs. The chapters on patient registration contain updates on the automated PRS.